Analysis of Legionella pneumophila serogroup 6 strains isolated from a hospital warm water supply over a three-year period by using genomic long-range mapping techniques and monoclonal antibodies

Legionnaires' disease in dental offices: Quantifying aerosol risks to dental workers and patients

Legionella pneumophila is an opportunistic bacterial respiratory pathogen that is one of the leading causes of drinking water outbreaks in the United States. Dental offices pose a potential risk for inhalation or aspiration of L. pneumophila due to the high surface area to volume ratio of dental unit water lines-a feature that is conducive to biofilm growth. This is coupled with the use of high-pressure water devices (e.g., ultrasonic scalers) that produce fine aerosols within the breathing zone. Prior research confirms that L. pneumophila occurs in dental unit water lines, but the associated human health risks have not been assessed. We aimed to: (1) synthesize the evidence for transmission and management of Legionnaires' disease in dental offices; (2) create a quantitative modeling framework for predicting associated L. pneumophila infection risk; and (3) highlight influential parameters and research gaps requiring further study. We reviewed outbreaks, management guidance, and exposure studies and used these data to parameterize a quantitative microbial risk assessment (QMRA) model for L. pneumophila in dental applications. Probabilities of infection for dental hygienists and patients were assessed on a per-exposure and annual basis. We also assessed the impact of varying ventilation rates and the use of personal protective equipment (PPE). Following an instrument purge (i.e., flush) and with a ventilation rate of 1.2 air changes per hour, the median per-exposure probability of infection for dental hygienists and patients exceeded a 1-in-10,000 infection risk benchmark. Per-exposure risks for workers during a purge and annual risks for workers wearing N95 masks did not exceed the benchmark. Increasing air change rates in the treatment room from 1.2 to 10 would achieve an ∼85% risk reduction, while utilization of N95 respirators would reduce risks by ∼95%. The concentration of L. pneumophila in dental unit water lines was a dominant parameter in the model and driver of risk. Future risk assessment efforts and refinement of microbiological control protocols would benefit from expanded occurrence datasets for L. pneumophila in dental applications.

Evaluation of an Optimal Epidemiological Typing Scheme for Legionella pneumophila with Whole-Genome Sequence Data Using Validation Guidelines

Sequence-based typing (SBT), analogous to multilocus sequence typing (MLST), is the current "gold standard" typing method for investigation of legionellosis outbreaks caused by Legionella pneumophila However, as common sequence types (STs) cause many infections, some investigations remain unresolved. In this study, various whole-genome sequencing (WGS)-based methods were evaluated according to published guidelines, including (i) a single nucleotide polymorphism (SNP)-based method, (ii) extended MLST using different numbers of genes, (iii) determination of gene presence or absence, and (iv) a kmer-based method. L. pneumophila serogroup 1 isolates (n = 106) from the standard "typing panel," previously used by the European Society for Clinical Microbiology Study Group on Legionella Infections (ESGLI), were tested together with another 229 isolates. Over 98% of isolates were considered typeable using the SNP- and kmer-based methods. Percentages of isolates with complete extended MLST profiles ranged from 99.1% (50 genes) to 86.8% (1,455 genes), while only 41.5% produced a full profile with the gene presence/absence scheme. Replicates demonstrated that all methods offer 100% reproducibility. Indices of discrimination range from 0.972 (ribosomal MLST) to 0.999 (SNP based), and all values were higher than that achieved with SBT (0.940). Epidemiological concordance is generally inversely related to discriminatory power. We propose that an extended MLST scheme with ∼50 genes provides optimal epidemiological concordance while substantially improving the discrimination offered by SBT and can be used as part of a hierarchical typing scheme that should maintain backwards compatibility and increase discrimination where necessary. This analysis will be useful for the ESGLI to design a scheme that has the potential to become the new gold standard typing method for L. pneumophila.

Investigation of the bacterial load and antibiotic susceptibility of dental units

The aim of this study was to evaluate the bacterial contamination level and to determine the antibiotic susceptibility of the isolated bacteria from dental unit waterlines (DUWLs) in Istanbul. Bacterial quality of DUWLs is very important, as patients and dental staff are regularly exposed to water and aerosols generated by the unit. If opportunistic pathogens such as Staphylococcus aureus, Pseudomonas aeruginosa, and Legionella pneumophila are present in DUWLs, patient and dental staff can be infected. One hundred water samples were collected from high-speed drills and input waters from 50 dental units. Aerobic heterotrophic bacteria counts and the presence of Legionella, Pseudomonas, oral streptococci, and Staphylococcus were investigated in dental unit waters and aerosol samples. In addition, the antibiotic susceptibility of the isolated and identified bacteria from DUWLs was examined. This research found that 37 out of 50 dental unit water samples exceeded the American Dental Association's limit of 200 colony-forming units (CFU)/mL(-1). Legionella, oral streptococci, and S. aureus were not detected in any water or aerosol samples, but P. aeruginosa was isolated in three DUWLs. Also, Pseudomonas and Staphylococcus were found in water and aerosol samples. Cefoperazone, ofloxacin, gentamicin, ciprofloxacin, and piperacillin were the most effective antibiotics against the isolated bacteria from DUWLs.

Microbial contamination of dental unit waterlines in Istanbul, Turkey

The water used in dental unit waterlines (DUWLs) acts as a coolant for the high-speed equipment and as an irrigant during dental treatments. There are kind of water tanks. DUWLs provide a favorable environment for microbial biofilm and multiplation primarily due to the high surface in the tubing and the character of fluid dynamics in narrow, smooth-walled waterlines. Biofilms can harbour opportunist pathogens such as Legionella sp., Pseudomonas sp. Several studies have shown that DUWLs have high levels of microbial contamination. Presence of high level of microbial contamination is an important problem for dentists and dental patients who are immunocompromised. We collected water samples from DUWLs of 20 private dental offices. We have determined that only 2 (3.4%) out of 59 dental unit water samples were found to meet the standard (<200 CFU.ml(-1)) for DUWLs water quality by American Dental Association (ADA). Of the 59 water samples examined, 14 (24%) were positive for Pseudomonas sp. and 18 (30.5%) were positive for fungi. The most common 14 bacterial strains and seven fungi were isolated. Of bacterial strains, 57.1% were identified: Majority of the bacterial species isolated from our samples was identified as Pseudomonas fluorescens, Pasteurella haemolytica, Photobacterium damsela, Ochrobacter anthropi, Moraxella sp., Aspergillus flavus, Penicillium expansum. Legionella sp. were not detected in all water samples.

Genetic diversity of Legionella pneumophila in hospital water systems

It has been shown that different patients who had acquired legionellosis in a hospital setting were infected with the same strain even years apart. However, there are no longitudinal data describing the molecular epidemiology of Legionella pneumophila strains that contaminate a water system. This raised the question if there are any shifts of L. pneumophila strains over time, or after carrying out control measures. Using genotyping on a large collection of isolates, we investigated in a retrospective study the distribution of L. pneumophila serogroups and PFGE types in six different hospitals of the University of Heidelberg between 1991 and 2001. A total of 2012 water samples were drawn for routine testing and for evaluation of control measures, 747 samples were positive for L. pneumophila. Serogroups were determined by latex agglutination or by direct fluorescence assay; and 515 L. pneumophila isolates from water systems and six from patients underwent PFGE typing after SfiI-restriction. We identified seven serogroups and 19 genotypes among the water isolates. Each hospital had one to four predominating PFGE types that were stable over the investigation period. The oldest buildings in hospitals 4 and 5 (built 1876 and 1907) had more types than the newest one (built 1986). In all hospitals PFGE types were identified that could be found only sporadically. Although each hospital had its own warm water supply, we identified types that could be found in more than one hospital. However, there was no overlap of types in buildings that were fed from different wells. Infrequently occurring nosocomial legionellosis (n=3) were only caused by predominant strains. Contamination of water supplies seemed to be dominated by stable genotypes, even after various control measures. Additional genotypes could be isolated sporadically, however, their pathogenetic relevance seemed to be questionable.

Measuring the validity of two in-office water test kits

BACKGROUND

The authors conducted a study to determine the validity of two commercially available in-office water test kits compared with a spread plate technique using the gold standard dehydrated culture medium R2A agar for monitoring the quality of dental treatment water.

METHODS

Over a 12-week period, one author monitored nine dental units in a dental school that each were equipped with an independent water reservoir. The author collected 351 split samples, cultured them using three test methods, counted bacterial colonies manually and assessed validity using two cutoff values: < or = 200 colony-forming units per milliliter (CFU/mL) (an American Dental Association goal) and < or = 500 CFU/mL (a Centers for Disease Control and Prevention [CDC] recommendation and a U.S. Environmental Protection Agency [EPA] mandate).

RESULTS

Of the 351 split samples processed, the in-office test kits' accuracy ranged from 25 to 69 percent, according to the ADA and CDC/EPA recommendations, compared with the R2A agar.

CONCLUSIONS

Overall, the in-office test kits underestimated bacteria levels, producing inaccurate measurements of bacterial levels compared with the R2A agar.

CLINICAL IMPLICATIONS

The data suggest that use of the two in-office test kits could result in a lack of compliance, owing to underestimating bacterial contamination with recognized recommendations for dental unit waterline quality.

Characterization of theLegionella anisapopulation structure by pulsed-field gel electrophoresis

We analysed 38 French isolates of Legionella anisa by means of pulsed-field gel electrophoresis (PFGE) with single or double digestion. Double digestion was more discriminatory than single digestion, and can thus be useful for epidemiological studies of L. anisa. Several isolates from different parts of France clustered together on the basis of their PFGE patterns (similarity cutoff of 80%), suggesting that the L. anisa population structure is homogenous or that a few clones of L. anisa strains have spread widely in France.

Persistent Legionella pneumophila colonization of a hospital water supply: efficacy of control methods and a molecular epidemiological analysis

After a nosocomial outbreak caused by Legionella pneumophila serogroup 5, the hospital water distribution system, which was found to be colonized by L. pneumophila serogroups 5 and 6, was decontaminated by the superheat and flush method and by installing an additional heat-shock unit in one of the hot water circuits. This unit exposed the recirculated water to a temperature of 80 degrees C. The efficacy of the decontamination measures was evaluated by monitoring the temperatures and legionella concentrations at different parts of the hot water distribution system. The genetic diversity of the colonizing legionella flora was examined using two genotyping methods: amplified fragment length polymorphism analysis (AFLP) and random amplified polymorphic DNA (RAPD) analysis. Selected serogroup 6 strains were also analyzed by sequence-based typing (SBT). The results indicated that long-term eradication of serogroup 5 strains was never achieved. Only one serogroup 6 strain was never isolated after the superheat and flush. In all, according to genetic fingerprints, the diversity of Legionella strains in a hospital water system remains stable over the years regardless of the use of recommended disinfection procedures.

A hospital-associated outbreak of Legionnaires' disease caused by Legionella pneumophila serogroups 4 and 10 with a common genetic fingerprinting pattern

An outbreak of eight cases of pneumonia caused by Legionella pneumophila non-serogroup 1 (non-sg 1) occurred at a Swedish university hospital in 1993. Including previous and subsequent sporadic cases, the total number of culture-positive patients was 13. Twelve available non-sg1 isolates from patients were compared to 50 environmental water isolates using a monoclonal antibody test for serogrouping and amplified fragment length polymorphism analysis (AFLP). Of the 12 hospital-associated Legionella non-sg 1 patient isolates, 4 were serogrouped as sg 4, 7 as sg 10, and one as sg 6. Using AFLP fingerprinting all serogroup (sg) 4 and 10 isolates were genetically related except for minor variations. Furthermore, sg 4 isolates were identical in AFLP to sg 10 isolates. Patient isolates were also identical to isolates found in the water system of several hospital buildings, but quite unrelated to isolates obtained in a subsequent outbreak at the same hospital caused by L. pneumophila sg 1. Serogroup variations in outbreaks may occur despite a common molecular fingerprinting pattern. Evidently, the L. pneumophila sg 4 and 10 strains were closely related genetically, which raises the question whether this variation in phenotype is due to a genetic event or to a variable phenotypic expression. Genetic fingerprinting should be used in conjunction with serogrouping in epidemiological investigations.

Characterization of members of the Legionellaceae family by automated ribotyping

In order to implement a new and reliable method for characterizing different species of Legionella, a genetic fingerprinting study with an automated ribotyping system (RiboPrinter) was completed with members of this genus which were deposited at the American Type Culture Collection. The RiboPrinter examined the different patterns of EcoRI digestion fragments from the rRNA operons of 110 strains, representing 48 of the 49 described Legionella species as well as 70 serogroups of those species. Distinctive and consistent patterns were obtained for the type strains of the 48 species investigated. Legionella pneumophila subsp. fraseri and L. pneumophila subsp. pascullei each generated a specific pattern, whereas L. pneumophila subsp. pneumophila produced six different fingerprint patterns. No correlation seemed to exist between the ribotypes obtained and the 15 serotypes of L. pneumophila. For the other species, those with two known serogroups presented two distinctive patterns with the RiboPrinter with the exception of L. hackeliae and L. quinlivanii, which yielded only one pattern. We also encountered ribotypes for strains which were not identified to the species level. The ribotypes generated for these strains with the RiboPrinter did not match those generated for known type strains, suggesting the putative description of new serogroups or species. Although the automated system did not have sufficient discriminatory ability to serve as an epidemiological tool in a clinical setting, it appeared to be a powerful tool for general genomic analysis of the Legionella isolates (e.g., determination of new species) and assessment of the interrelationship among Legionella strains through the RiboPrinter database connection.

A multicenter evaluation of genotypic methods for the epidemiologic typing of Legionella pneumophila serogroup 1: results of a pan-European study

OBJECTIVES: To compare genotypic methods for epidemiologic typing of Legionella pneumophila serogroup (sg) 1, in order to determine the best available method within Europe for implementation and standardization by members of the European Working Group on Legionella Infections. METHODS: Coded isolates (114) of L. pneumophila sg 1 comprising one epidemiologically 'unrelated' (79) and one 'related' panel of isolates (35) were sent to 12 laboratories in 11 European countries. Analysis was undertaken in each laboratory using one or more of the following methods: ribotyping, restriction fragment length polymorphism analysis, restriction endonuclease analysis, pulsed-field gel electrophoresis (PFGE), PCR using arbitrary/repeat sequence primers (AP-, AP/rep-PCR), and amplified fragment length polymorphism (AFLP) analysis. Results were analyzed visually or using gel analysis software. Each method was assessed for its: index of discrimination (D), epidemiologic concordance (E), speed of application and ease of use. In addition, phenotypic analysis was performed in two laboratories using monoclonal antibodies (mAbs). RESULTS: The D of each of the genotypic methods ranged from 0.840 for ribotyping to 0.990 for PFGE using Sfil: E ranged from 0.06 for AP- and AP/rep-PCR to 1.00 for ribotyping using Pstl/EcoRI and AFLP: in general, E was inversely related to D. Although offering only limited discrimination (D=0.838), mAb typing was both rapid and highly epidemiologically concordant (E=1.00). CONCLUSIONS: Two methods, PFGE using Sfil and AFLP, were selected for further study. AFLP is rapid and highly epidemiologically concordant (E=1.00), but is not highly discriminatory. This method will be developed as a rapid screening tool. PFGE using Sfil is highly discriminatory but, in the present study, yielded low values of E (0.12-0.71). Attempts will be made to rigorously standardize this method for use as the reference method. Primary screening of isolates by mAb subgrouping is recommended.

Legionella: from environmental habitats to disease pathology, detection and control

Studies on Legionella show a continuum from environment to human disease. Legionellosis is caused by Legionella species acquired from environmental sources, principally water sources such as cooling towers, where Legionella grows intracellularly in protozoa within biofilms. Aquatic biofilms, which are widespread not only in nature, but also in medical and dental devices, are ecological niches in which Legionella survives and proliferates and the ultimate sources to which outbreaks of legionellosis can be traced. Invasion and intracellular replication of L. pneumophila within protozoa in the environment play a major role in the transmission of Legionnaires' disease. Protozoa provide the habitats for the environmental survival and reproduction of Legionella species. L. pneumophila proliferates intracellularly in various species of protozoa within vacuoles studded with ribosomes, as it also does within macrophages. Growth within protozoa enhances the environmental survival capability and the pathogenicity (virulence) of Legionella. The growth requirements of Legionella, the ability of Legionella to enter a viable non-culturable state, the association of Legionella with protozoa and the occurrence of Legionella within biofilms complicates the detection of Legionella and epidemiological investigations of legionellosis. Polymerase chain reaction (PCR) methods have been developed for the molecular detection of Legionella and used in environmental and epidemiological studies. Various physical and chemical disinfection methods have been developed to eliminate Legionella from environmental sources, but gaining control of Legionella in environmental waters, where they are protected from disinfection by growing within protozoa and biofilms, remains a challenge, and one that must be overcome in order to eliminate sporadic outbreaks of legionellosis.

Multiple types of Legionella pneumophila serogroup 6 in a hospital heated-water system associated with sporadic infections

Five sporadic cases of nosocomial Legionnaires' disease were documented from 1989 to 1997 in a hospital in northern Italy. Two of them, which occurred in a 75-year-old man suffering from ischemic cardiopathy and in an 8-year-old girl suffering from acute leukemia, had fatal outcomes. Legionella pneumophila serogroup 6 was isolated from both patients and from hot-water samples taken at different sites in the hospital. These facts led us to consider the possibility that a single clone of L. pneumophila serogroup 6 had persisted in the hospital environment for 8 years and had caused sporadic infections. Comparison of clinical and environmental strains by monoclonal subtyping, macrorestriction analysis (MRA), and arbitrarily primed PCR (AP-PCR) showed that the strains were clustered into three different epidemiological types, of which only two types caused infection. An excellent correspondence between the MRA and AP-PCR results was observed, with both techniques having high discriminatory powers. However, it was not possible to differentiate the isolates by means of ribotyping and analysis of rrn operon polymorphism. Environmental strains that antigenically and chromosomally matched the infecting organism were present at the time of infection in hot-water samples taken from the ward where the patients had stayed. Interpretation of the temporal sequence of events on the basis of the typing results for clinical and environmental isolates enabled the identification of the ward where the patients became infected and the modes of transmission of Legionella infection. The long-term persistence in the hot-water system of different clones of L. pneumophila serogroup 6 indicates that repeated heat-based control measures were ineffective in eradicating the organism.

Detecting legionellosis by unselected culture of respiratory tract secretions and developing links to hospital water strains

For a 13-month period, all respiratory tract secretions submitted for routine bacteriology from a large hospital complex were cultured for legionella, irrespective of clinical diagnosis and laboratory requests. Ten cases of legionellosis were detected in this manner, three of which met a strict epidemiological definition of hospital-acquired. Therefore, the 16 warm-water systems of the hospitals, spread out over two locations, were examined for the presence of legionella. Legionella pneumophila was found in 15 warm water systems, with a distinct pattern of serogroups between the two locations. Legionella of the same serogroups as those isolated from patients were present in each hospital water supply. The isolates were further typed by monoclonal antibodies and by genomic macrorestriction analysis. Similarity between clinical and environmental isolates was found in seven cases. In these cases, acquisition from the hospital water supply appears very likely. The strains of the remaining three patients did not match those in hospital water, suggesting that community-acquired legionellosis was occurring as well. This study suggests that routinely culturing respiratory tract secretions of pneumonia patients for legionella can help diagnose unsuspected cases of legionellosis. Typing legionella strains beyond the serogroup level with tools such as macrorestriction analysis is useful to define sources of infection, which can then be targeted for control measures.

Epidemiological and environmental investigations of Legionella pneumophila infection in cattle and case report of fatal pneumonia in a calf

A fatal pneumonia due to Legionella pneumophila was diagnosed in a young calf reared in a dairy herd located in northern Italy. Clinical symptoms consisted of watery diarrhea, hyperthermia, anorexia, and severe dyspnea. The pathological and histological findings were very similar to those observed in human legionellosis. Legionella pneumophila serogroup 1 (SG1) and SG10 were isolated from the calfs lung, and L. pneumophila SG1 was isolated from the calfs liver. L. pneumophila SG1 was also demonstrated in the lung tissue by immunofluorescence and immunohistochemical examinations. Nine of 10 L. pneumophila SG1 isolates belonged to the Olda subtype, and 1 belonged to the Camperdown subtype. A very low prevalence of antibodies to Legionella was detected in cows and calves reared in the same herd. Cultures of aqueous sediment of an old electric water heater which supplied hot water for the feeding of the calves yielded L. pneumophila SG1. Four of the colonies tested belonged to the Olda subtype. Ten clinical and four environmental isolates were examined for the presence of plasmids. Nine of them were also examined by pulsed-field gel electrophoresis assay, and the same patterns were found for L. pneumophila SG1 Olda strains isolated from the calf and from the electric heater. This is the first report of a documented case of a naturally occurring Legionella pneumonia in an animal. Cattle probably act as accidental hosts for legionellae, much the same as humans.

Molecular epidemiology of an outbreak of Legionnaires' disease associated with a cooling tower in Genova-Sestri Ponente, Italy

Fatty acid profile analysis, monoclonal antibody (MAb) subtyping, pulsed-field gel electrophoresis (PFGE), arbitrarily primed polymerase chain reaction (AP-PCR), and ribotyping were used to compare clinical and environmental Legionella pneumophila serogroup 1 isolates from an outbreak of Legionnaires' disease presumptively associated with cooling towers. According to the Oxford subtyping scheme, the MAb subtype of patients' isolates and of two strains originating from a cooling tower was Pontiac, whereas the other isolates were subtype Olda. The strains showed no intrinsic strain-to-strain difference in fatty acid profiles, and ribotyping and length polymorphism of the 16S-23S rDNA intervening regions failed to reveal any differences between the isolates. Conversely, PFGE and AP-PCR appeared to be more discriminatory, as the same genomic profile was found for the clinical and some environmental strains. Meteorologic and epidemiological data and the results of molecular analysis of the Legionella pneumophila serogroup 1 isolates support the hypothesis that the infection was transmitted from one of the cooling towers to the indoor environment of the same building, to homes in proximity that had open windows, and to the streets. In fact, the outbreak diminished and later ended after a part in the tower was replaced. This investigation demonstrates the utility of combined molecular methods (i.e., phenotypic and genomic typing) in comparing epidemiologically linked clinical and environmental isolates. Finally, the outbreak confirms the risk of Legionnaires' disease posed by cooling towers, mainly when atmospheric thermal and humidity inversions occur. This finding emphasizes the need to determine whether the source of infection is in the living or working environment or somewhere else.

Molecular techniques reveal high prevalence of Legionella in dental units

Legionella bacteria are ubiquitous in freshwater aquatic systems, and humans are infected by them primarily through inhalation of contaminated aerosols. This study analyzed a total of 47 water samples from dental lines in private dental offices and university and hospital dental clinics for Legionella using the polymerase chain reaction, direct fluorescent antibody staining and culture techniques. The typical temperature of dental waterlines (23 C) combined with Legionella's ability to form biofilms, stagnation of the water in the lines and a low chlorine residual all potentially create a unique niche for this microorganism.

Biofilm and the dental office

The author provides a brief overview of the basic processes involved in biofilm formation and explores the implications these biofilms have for health care facilities such as hospitals and dental offices. Included with this article are suggestions dentists may consider for improving water quality and a white paper on waterlines adopted by the ADA.

DNA fingerprinting by pulsed-field gel electrophoresis to investigate a nosocomial pneumonia caused by Legionella bozemanii serogroup 1

We typed 18 isolates of Legionella bozemanii obtained from clinical and environmental sources by pulsed-field gel electrophoresis. Each of the unrelated strains showed individual restriction patterns of the genomic DNA when either the SfiI or NotI restriction enzyme was used. One strain isolated from a patient with nosocomial legionellosis and two strains from the corresponding hospital water supply were indistinguishable, arguing for a transmission of L. bozemanii from the water supply to the patient. In conclusion, macrorestriction analysis is a valuable tool for studies of the molecular epidemiology of L. bozemanii.

DNA polymorphisms in strains of Legionella pneumophila serogroups 3 and 4 detected by macrorestriction analysis and their use for epidemiological investigation of nosocomial legionellosis

Genomic DNAs of clinical and environmental isolates of Legionella pneumophila belonging to serogroups 3 and 4 were analyzed by macrorestriction analysis by pulsed-field gel electrophoresis. The restriction enzymes SfiI and NotI allowed easy visual separation of epidemiologically unrelated serogroup 3 strains. Three unrelated serogroup 3 strains that were isolated from different locations were identical by this genome mapping technique. Five unrelated serogroup 4 strains were separable by this technique. The electrophoretic patterns obtained after SfiI or NotI cleavage of the DNA of strains isolated from four patients with hospital-acquired legionellosis were identical to the patterns of strains isolated from the hot water supply systems of the buildings in which the patients were hospitalized. In conclusion, macrorestriction analysis is a valuable tool for epidemiological studies of infections caused by L. pneumophila serogroups 3 and 4.

Restriction fragment length polymorphism of rRNA genes for molecular typing of members of the family Legionellaceae

Typing of Legionella pneumophila remains important in the investigation of outbreaks of Legionnaires' disease and in the control of organisms contaminating hospital water. We found that the discriminatory power of a nonradioactive ribotyping method could be improved by combining results obtained with four restriction enzymes (HindIII, NciI, ClaI, and PstI). Fifty-eight clinical and environmental L. pneumophila strains including geographically unrelated as well as epidemiologically connected isolates were investigated. Epidemiologically related strains had the same ribotypes independent of the combinations of enzymes used. Some strains belonging to the same serogroup were assigned to different ribotypes, and some ribotypes contained members of different serogroups, indicating, as others have found, that serogroup and genotype are not always related. The discriminatory power of the method was estimated by calculating an index of discrimination (ID) for individual enzymes and combinations thereof. The combined result with all four enzymes was highly discriminatory (ID = 0.97), but results for three enzymes also yielded ID values acceptable for epidemiological purposes. In addition, the testing of 27 type strains and 6 clinical isolates representing Legionella species other than L. pneumophila indicated that ribotyping might be of value for species identification within this genus, as previously suggested.

Genomic heterogenicity amongst phenotypically similar Legionella micdadei strains

Nine unrelated Legionella micdadei strains isolated from clinical and environmental samples have been characterized biochemically, serologically using polyclonal and monoclonal antibodies and by macrorestriction analyses using pulsed-field gel electrophoresis. All strains were positive in the Bromocresol purple spot test and grew as blue colonies on dye-containing media. They were positive for catalase, weakly positive for oxidase, and negative for sodium-hippurate hydrolysis, beta-lactamase and gelatinase. None of the strains showed autofluorescence under long-wave ultraviolet light. A panel of six monoclonal antibodies raised against the ATCC strain TATLOCK revealed no significant differences in the surface antigen composition of the L. micdadei strains. None of these monoclonal antibodies reacted with L. maceachernii and L. longbeachae serogroup 2, the only species that cross-react with polyclonal antisera. Each of the nine L. micdadei strains showed individual restriction patterns of the genomic DNA when using both SfiI and NotI restriction enzymes in the pulsed-field gel electrophoresis. Macrorestriction analysis is a valuable tool for studies on the molecular epidemiology of L. micdadei.

Epidemiologic investigation by macrorestriction analysis and by using monoclonal antibodies of nosocomial pneumonia caused by Legionella pneumophila serogroup 10

A 67-year-old woman was hospitalized with an acute pneumonia of the left lower lobe. Legionella pneumophila serogroup 10 was cultured from two sputum specimens taken on days 18 and 20 and was also detected by direct immunofluorescence assay by using a commercially available species-specific monoclonal antibody as well as serogroup 10-specific monoclonal antibodies. Antigenuria was detected in enzyme-linked immunosorbent assays by using serogroup 10-specific polyclonal and monoclonal antibodies. In the indirect immunofluorescence test rising antibody titers against serogroups 1, 4, 5, 8, 9, 10, 14, and 15 were found in serum, with the highest titers found against serogroups 8, 9, and 10. L. pneumophila serogroups 10 and 6 and a strain that reacted with serogroup 4 and 14 antisera were cultured from both central and peripheral hot water systems of the hospital. Macrorestriction analyses of the genomic DNAs by pulsed-field gel electrophoresis showed that the isolate from the patient was identical to the serogroup 10 strains from the hospital hot water system. In contrast, the genomic DNAs of 16 unrelated L. pneumophila serogroup 10 strains showed 12 different restriction patterns. Monoclonal antibody subtyping revealed only minor differences in L. pneumophila serogroup 10 strains isolated from different sources. In conclusion, macrorestriction analysis is a valuable tool for studying the molecular epidemiology of L. pneumophila serogroup 10.

Analysis of Legionella pneumophila strains associated with nosocomial pneumonia in a neonatal intensive care unit

A premature child received continuous mechanical ventilation in a neonatal intensive care unit. On day 10 of his life he developed pneumonia due to Legionella pneumophila serogroup 1, monoclonal subtype Bellingham. The strain was cultured from a tracheal secretion taken on day 10 and detected by immunofluorescence using monoclonal antibodies on days 10, 12 and 17. Legionella pneumophila serogroups 1 and 6 (10(2)-4 x 10(4) cfu/l) were cultured from both central and peripheral hot water systems. Monoclonal antibody testing, macrorestriction analysis of the genomic DNA using pulse-field electrophoresis, and electrophoretic alloenzyme typing showed the isolate from the child to be identical to the serogroup 1 strains from the hot water system. Four unrelated Legionella strains of the same monoclonal subgroup Bellingham were studied for comparison. Legionellae were also isolated from two other incubators, but no clinical or microbiological indications of legionellosis were found in the neonates hospitalised there. Serogroup 1 strains isolated from the patient and from the hot water system and serogroup 6 isolates from the hot water supply were able to multiply in cultured Acanthamoeba castellanii cells and in guinea pigs. The serogroup 6 strain, although prevalent in the incubators, was not found in any of the clinical specimens by either culture of immunofluorescence.

Genetic approaches to study Legionella pneumophila pathogenicity

Legionella pneumophila is an intracellular pathogen replicating in human macrophages during the course of infection of the lungs. Infection by legionellae often leads to severe pneumonia, termed Legionnaires' disease. Genetic approaches to identify the factors responsible for L. pneumophila pathogenicity started with the construction of genomic libraries in Escherichia coli. Various L. pneumophila-specific genes were cloned in E. coli K-12 by identification using functional assays, antibody screening and hybridization ('reverse genetics'). By disrupting the genes via allelic exchange, mutants have been created to assess the influence of the factors on pathogenicity. Among the cloned genes, only for the gene product of the mip gene, encoding a 24-kDa surface-associated protein (macrophage infectivity potentiator) unequivocal evidence for its contribution to pathogenicity could be provided. Two hemolytic factors that have been cloned do not seem to play a role in L. pneumophila pathogenicity. Genetic systems for transposon mutagenesis of the L. pneumophila genome (Tn5, Tn903dIIlacZ, MudphoA), including Tn phoA shuttle mutagenesis, have been established and specifically adapted to identify mutants which displayed an impaired capability to multiply inside macrophages and with a reduced in vivo virulence. Furthermore, by complementation of avirulent mutants, genetic loci could be identified which restored the virulence.

Clonal differentiation of uropathogenic Escherichia coli isolates of serotype O6:K5 by fimbrial antigen typing and DNA long-range mapping techniques

Escherichia coli isolates of serotype O6:K5 are the most common causative agents of cystitis and pyelonephritis in adults. To answer the question, as to whether strains of this particular serotype represent one special clonal group, out of a collection of 34 serotype O6:K5 isolates [Zingler et al. (1990) Zentralbl. Bakteriol Mikrobiol Hyg [A] 274:372-381] 15 strains were selected and analyzed in detail. The flagellar (H) antigen and the outer membrane protein (OMP) pattern were determined. Further serum resistance properties and the genetic presence and expression of other virulence factors, including hemolysin, aerobactin, P fimbriae, S/F1C fimbriae and type 1 fimbriae was evaluated. In addition the XbaI-macrorestriction pattern of ten representative isolates was elaborated and the fimbrial (F) antigen type of the P fimbriae was determined, to obtain the complete O:K:H:F pattern. These analyses could clearly show that the O6:K5 isolates do not represent one clonal group. The XbaI-macrorestriction profiles were heterogeneous and marked differences in the hybridization patterns, using virulence-associated gene probes in Southern hybridization of long-range-separated genomic DNA, were observed among the strains. However, some of strains showed similarities in the genomic profiles, arguing for clonal groupings among the O6:K5 isolates. Interestingly the strains grouped together exhibited the same fimbrial F type that many indicate a coincidence of this phenotypic trait with clonality.

Clonal analysis of Escherichia coli serotype O6 strains from urinary tract infections

A total of 36 Escherichia coli urinary tract isolates (UTI) of serotype O6, with different combinations of capsule (K) and flagellin (H) antigens, were analysed according to the outer membrane pattern (OMP), serum resistance properties, mannose-resistant hemagglutination using various types of erythrocytes, and also for the genetic presence and the expression of P-fimbriae, S fimbriae/F1C fimbriae, Type 1 fimbriae, aerobactin and hemolysin. Twenty selected strains were further analysed by pulsed field gel electrophoresis (PFGE), elaborating genomic profiles by XbaI cleavage and subsequent Southern hybridization to virulence-associated DNA probes. It could be shown that O6 UTI isolates represent a highly heterogeneous group of strains according to the occurrence and combination of these traits. Relatedness on the genetic and the phenotypic level was found for some of the strains exhibiting the same O:K:H:F serotype. DNA long-range mapping further indicated some interesting features, according to the copy number and the genomic linkage of virulence genes.